Provider Demographics
NPI:1831124668
Name:BAILEY, ELLEN
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3255 BRIGHTON HENRIETTA TL ROAD
Mailing Address - Street 2:STE 102
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-2853
Mailing Address - Country:US
Mailing Address - Phone:585-427-7610
Mailing Address - Fax:585-427-7410
Practice Address - Street 1:3255 BRIGHTON HENRIETTA TL ROAD
Practice Address - Street 2:STE 102
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2853
Practice Address - Country:US
Practice Address - Phone:585-427-7610
Practice Address - Fax:585-427-7410
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11225304OtherCAQH
NYRB3679Medicare PIN
NY11225304OtherCAQH